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Pelvic Pain in Women

By

David H. Barad

, MD, MS, Center for Human Reproduction

Last full review/revision May 2022| Content last modified May 2022
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Pelvic pain is discomfort that occurs in the lowest part of the abdomen. Pain that occurs externally in the genital area (vulva, or labia) is called vulvar pain. Many women have pelvic pain. Pain is considered chronic if it continues to occur for more than 3 to 6 months.

Pelvic pain can be a gynecologic symptom. That is, it can result from a problem affecting the female reproductive system. Or it may be caused by problems in the urinary, digestive, or musculoskeletal system.

The pain may start suddenly or gradually. The pain may gradually increase in intensity, sometimes occurring in waves. It may be constant or come and go. It may be sharp or dull or crampy (like menstrual cramps), or some combination.

Causes of Pelvic Pain

Disorders that can cause pelvic pain include

  • Gynecologic disorders—those that affect the reproductive organs (vagina, cervix, uterus, fallopian tubes, and ovaries)

  • Disorders that affect other organs in the pelvis, such as the bladder, lower part of the ureters, urethra, rectum, appendix, or pelvic floor (the muscles, ligaments, and tissues that support the organs of the pelvis)

  • Disorders that affect structures near but outside the pelvis, such as the abdominal wall, intestine, kidneys, or upper part of the ureters

Often, it is difficult for doctors to identify what is causing pelvic pain.

Gynecologic disorders

Gynecologic disorders may be related to the menstrual cycle or not.

Overall, the most common gynecologic causes of pelvic pain include

Fibroids Fibroids A fibroid is a noncancerous tumor composed of muscle and fibrous tissue. It is located in the uterus. Fibroids can cause pain, abnormal vaginal bleeding, constipation, repeated miscarriages... read more Fibroids in the uterus are noncancerous tumors composed of muscle and fibrous tissue. They can cause pelvic pain if they put pressure on other organs, are degenerating, or cause excessive bleeding or cramping. Most uterine fibroids do not cause pain.

Many other gynecologic disorders can cause pelvic pain (see table Some Gynecologic Causes of Pelvic Pain Some Causes of Pelvic Pain in Women* Some Causes of Pelvic Pain in Women* ).

Other disorders

Other causes of pelvic pain include

Psychologic factors, especially stress and depression Depression A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to... read more , may contribute to any kind of pain, including pelvic pain, but, by themselves, rarely cause pelvic pain. Women or girls that have had sexual trauma may develop chronic pelvic pain.

Evaluation of Pelvic Pain

Usually, pelvic pain is not an emergency, but when a woman has new, sudden, very severe pain in the lower abdomen or pelvis, medical attention should be sought as soon as possible. Sometimes, emergency surgery is required. Disorders that usually require emergency surgery include

Doctors check for pregnancy in all girls and women of childbearing age.

Warning signs

In women with pelvic pain, certain symptoms are cause for concern:

When to see a doctor

Women with most warning signs should see a doctor immediately.

Women may need to be seen the same day or within a few days if they have

  • Vaginal bleeding after menopause

  • Pain that is constant or steadily worsening

If women have new pain that is not constant and is not worsening or if they have pain that is recurring or chronic, they should schedule a visit when practical, but a delay of several days is usually not harmful.

Mild menstrual cramps are normal. Menstrual cramps do not require evaluation unless they are very painful.

What the doctor does

The doctor does a quick evaluation to see if emergency treatment is needed. Doctors ask the woman questions about her symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see table Some Gynecologic Causes of Pelvic Pain Some Causes of Pelvic Pain in Women* Some Causes of Pelvic Pain in Women* ).

Doctors ask about the pain:

  • Whether it begins suddenly or gradually

  • Whether it is sharp or dull

  • How severe it is

  • When it occurs in relation to the menstrual cycle, eating, sleeping, sexual intercourse, physical activity, urination, and bowel movements

  • Whether any other factors worsen or ease the pain

The woman is asked about other symptoms, such as vaginal bleeding, a discharge, and light-headedness.

The woman is asked to describe past pregnancies and menstrual periods. Doctors also ask whether she has had any disorders that can cause pelvic pain and whether she has had abdominal or pelvic surgery.

Doctors may ask about stress, depression, and other psychologic factors to determine whether these factors may be contributing to the pain, especially if the pain is chronic.

Certain groups of symptoms that accompany pelvic pain suggest a type of medical condition. For example,

The physical examination starts with checking vital signs, such as temperature, blood pressure, and pulse. Then doctors focus on the abdomen and pelvis. Doctors gently feel the abdomen and do a pelvic examination Gynecologic Examination For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to... read more . During an examination, the abdomen or other areas may feel tender if touched. This evaluation helps doctors determine which organs are affected and whether an infection is present. Often, doctors also check the rectum for abnormalities.

Table

Testing

The following tests are routinely done:

  • Urine tests

  • A pregnancy test if women are of childbearing age

A pregnancy test is done if a woman is in her reproductive years. A urine pregnancy test is usually done first. If a very early pregnancy is possible and the urine test is negative, a blood test for pregnancy is done. The blood test is more accurate than the urine test when a pregnancy is less than 5 weeks.

If a woman is pregnant and has pain or vaginal bleeding, ultrasonography is done to rule out an ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is attachment (implantation) of a fertilized egg in an abnormal location. In an ectopic pregnancy, the fetus cannot survive. When an ectopic pregnancy ruptures, women often... read more . For ultrasonography, doctors use a handheld ultrasound device that is placed on the abdomen or inside the vagina. Ultrasonography of the pelvis is done for many reasons. It is done whenever doctors think a gynecologic disorder may be the cause of the symptoms and the symptoms have begun suddenly, recur, or are severe.

If results of ultrasonography are unclear, other tests, such as a series of blood tests or laparoscopy, are done to rule out ectopic pregnancy. For the blood tests, doctors measure levels of a hormone produced by the placenta called human chorionic gonadotropin (hCG). If hCG levels are low, the pregnancy may be too early for ultrasonography to detect. If levels are high and ultrasonography does not detect a pregnancy, ectopic pregnancy is possible. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to directly look for an ectopic pregnancy or other causes of pelvic pain.

Tests depend on which disorders are suspected. Tests may include

Treatment of Pelvic Pain

If the cause of the pelvic pain is identified, it is treated if possible. Pain related to the menstrual cycle (such as cramps or endometriosis) may be treated with hormonal contraceptives Hormonal Methods of Contraception Contraceptive hormones can be Taken by mouth (oral contraceptives) Inserted into the vagina (vaginal rings) Applied to the skin (patch) Implanted under the skin read more Hormonal Methods of Contraception .

Pain relievers may also be needed. Initially, pain is treated with nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Women who do not respond well to one NSAID may respond to another. If NSAIDs are ineffective, other pain relievers or hypnosis may be tried.

If the pain involves muscles, rest, heat, or physical therapy may help.

Rarely, when women have severe pain that persists despite treatment, surgery, such as laparoscopy to treat endometriosis or an ovarian cyst or hysterectomy (surgery to remove the uterus), can be done.

Essentials for Older Women: Pelvic Pain

In older women, common causes of pelvic pain may be different because some disorders that cause pelvic pain or discomfort become more common as women age, particularly after menopause. Obviously, disorders related to menstrual periods are no longer possible causes.

Common disorders in older women include

After menopause, estrogen levels decrease, weakening many tissues, including bone, muscles (such as those supporting the bladder), and tissues around the vagina and urethra. As a result, pelvic fractures and bladder infections become more common.

Also, this weakening may contribute to pelvic organ prolapse, which may cause symptoms as women become older. In these disorders, weakened or damaged tissues in the pelvis can no longer hold the uterus, vagina, or other organs in the pelvis in place. As a result, one or more of these organs may drop down (prolapse) and women may feel pressure in the vagina or have urinary incontinence or difficulty having a bowel movement.

Symptoms that affect the vagina and urinary tract after menopause are called the genitourinary syndrome of menopause (formerly called vaginal atrophy or atrophic vaginitis). These symptoms include vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections. This condition may make sexual intercourse painful, and women may describe or experience this pain as pelvic pain.

Evaluation

Evaluation is similar to that for younger women, except doctors pay particular attention to symptoms of urinary and digestive tract disorders that are common in older women. Older women should see a doctor promptly if they

  • Suddenly lose weight or their appetite

  • Suddenly start having indigestion

  • Feel bloated

  • Have a sudden change in bowel movements

The doctor then does an examination to make sure that the cause is not ovarian or endometrial cancer.

If the vaginal lining is thin in a woman with pelvic pain, doctors ask her questions to determine whether she is sexually active. If so, doctors may recommend a break from sexual intercourse until symptoms subside, or they may prescribe an estrogen cream Forms of hormonal therapy Forms of hormonal therapy .

Key Points

  • Many women have pelvic pain.

  • Many disorders (related to reproductive organs or other nearby organs) can cause pelvic pain.

  • Doctors can determine likely causes based on a description of the pain, its relationship to the menstrual cycle, and results of a physical examination.

  • If women are of childbearing age, a pregnancy test is always done.

  • Urine tests and usually other tests, such as blood tests and ultrasonography of the pelvis, are done to confirm the suspected diagnosis.

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